Nursing Applications Nursing Application Form Nursing Reference Questionnaire Degree Options Practical Nurse Practical Nurse application This application is for the PN program located at the Nevada campus only. Personal InformationName* First Middle Last Birth Date* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Crowder Student ID Number*Social Security Number*Email* Enter Email Confirm Email Phone Number*Alternate Phone Number*Are you a US Citizen?*YesNoHave you ever been convicted as an adult offender for any crime, including DWI or DUI?*YesNo Licensures or Certifications* CNA CMA RMA EMT Paramedic CPR Other Please mark all licensures or certifications that you have in the medical field:If "Other", please specify.EducationList high school or GED and colleges AttendedName of School*Address of School* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Degree or Hours Earned*Add a Second SchoolYesNo EducationList high school or GED and colleges AttendedName of School*Address of School* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Degree or Hours Earned*Add a Third SchoolYesNo EducationList high school or GED and colleges AttendedName of School*Address of School* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Degree or Hours Earned* TranscriptsI have requested all official transcripts to be sent to Crowder College Records Department*YesNoOccupational ExperienceList all employment within the past 5 years, start with the last date of employment (Employers may be contacted as references)EmployerEmployer Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Employer Phone NumberType of EmploymentStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Add a Second EmployerYesNo Occupational ExperienceList all employment within the past 5 years, start with the last date of employment (Employers may be contacted as references)Employer*Employer Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Employer Phone NumberType of Employment*Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Add a Third EmployerYesNo Occupational ExperienceList all employment within the past 5 years, start with the last date of employment (Employers may be contacted as references)Employer*Employer Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Employer Phone NumberType of Employment*Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Describe a positive contribution you would bring to the Crowder learning environment.*Community service completed in the last 5 years, please include date and description of service. ReferencesPlease list the names, phone numbers, and email addresses of three persons (not relatives or friends) who can evaluate your aptitude for the nursing profession. Recommended references include supervisors, coworkers, college instructors, etc... (Employers who can speak to work ethic are often a good option.) Reference questionnaires will be delivered by email to the references indicated below. You will be notified by email when each of your references completes their questionnaire.First Reference Name* First Last First Reference Phone Number*First Reference Email* Enter Email Confirm Email Second Reference Name* First Last Second Reference Phone Number*Second Reference Email* Enter Email Confirm Email Third Reference Name* First Last Third Reference Phone Number*Third Reference Email* Enter Email Confirm Email AcknowledgementsAcknowledgement 1* Yes I UnderstandI do hereby certify that the above information is complete and correct to the best of my knowledge under penalty of perjury.Acknowledgement 2* Yes I UnderstandI understand that any question answered in a false manner will result in the application being void and therefore not considered. I understand that I will not be considered for admission into the nursing program until I have completed the application process as outlined in the application information sheet."The Family Educational Rights and Privacy Act of 1974", Public Law 93-380 as amended and signed into law by President Ford on December 31, 1974, states that enrollees have the right to examine confidential files. It also states that they may waive this right if they do so desire. The law provides that references may be either confidential or non-confidential at the option of the registrant. The registrant has the option to inspect the references in a non-confidential file. Confidential references are those which the registrant has waived the right to see. Please consider the following in making a decision to have confidential or non-confidential references. 1. School officials prefer to see confidential references, believing the references are more frank in such credentials. The limited number of studies which have been made of confidential vs. non-confidential references Indicate a preference of both hiring officials and college faculty for confidential or enclosed references. 2. Registrants should be most selective in asking persons to write references for them. The persons selected should know the registrant well and be able to state facts and competencies of the registrant. 3. Writers of references will be informed at the time of writing that the reference is confidential or that the registrant will be permitted to see the reference. I Have Elected:*A Confidential FileA Non-Confidential FileComments/messages for the application committee regarding your application?By execution of the application, I do hereby authorize Crowder College or it's representatives to verify all information contained within this application, and do waive any privilege I may have as to confidentiality to Crowder College or it's representatives, and I do authorize any agency - - educational, health, or law enforcement - - to furnish to Crowder College or it's representatives the information necessary to validate the information contained upon my application to the Nursing Department. Signature*Type in full name to sign and affirm this applicationDate Signed* Date Format: MM slash DD slash YYYY Thank you for your interest in Crowder's Practical Nursing Program. If you have any questions call 417-667-0518 ext. 5238 or email nursing@crowder.eduPlease attach transcript (required)Accepted file types: doc, docx, jpg, pdf.Accepted file types: doc, docx, jpg, pdf Some users are currently experiencing difficulty attempting to upload these documents. If your documents will not upload please send them as email attachments to nursing@crowder.edu.Please attach TEAS score to this field (required)Accepted file types: doc, docx, jpg, pdf.Accepted file types: doc, docx, jpg, pdf Some users are currently experiencing difficulty attempting to upload these documents. If your documents will not upload please send them as email attachments to nursing@crowder.edu.Please attach Family Care Safety Registry to this field (required)Accepted file types: doc, docx, jpg, pdf.Accepted file types: doc, docx, jpg, pdf Some users are currently experiencing difficulty attempting to upload these documents. If your documents will not upload please send them as email attachments to nursing@crowder.edu.Please attach any Medical Certification to this field (optional)Accepted file types: doc, docx, jpg, pdf.Accepted file types: doc, docx, jpg, pdf Some users are currently experiencing difficulty attempting to upload these documents. If your documents will not upload please send them as email attachments to nursing@crowder.edu.Please attach any Medical Certification to this field (optional)Accepted file types: doc, docx, jpg, pdf.Accepted file types: doc, docx, jpg, pdf Some users are currently experiencing difficulty attempting to upload these documents. If your documents will not upload please send them as email attachments to nursing@crowder.edu.Please attach any Medical Certification to this field (optional)Accepted file types: doc, docx, jpg, pdf.Accepted file types: doc, docx, jpg, pdf Some users are currently experiencing difficulty attempting to upload these documents. If your documents will not upload please send them as email attachments to nursing@crowder.edu.Please attach any other supporting documents (optional)Accepted file types: doc, docx, jpg, pdf.Accepted file types: doc, docx, jpg, pdf Some users are currently experiencing difficulty attempting to upload these documents. If your documents will not upload please send them as email attachments to nursing@crowder.edu.Please attach any other supporting documents (optional)Accepted file types: doc, docx, jpg, pdf.Accepted file types: doc, docx, jpg, pdf Some users are currently experiencing difficulty attempting to upload these documents. If your documents will not upload please send them as email attachments to nursing@crowder.edu.The Family Care Safety Registry may be accessed at https://health.mo.gov/safety/fcsr/ For additional information please see the Nursing Student Handbook and the Missouri Revised Statutes Chapter 335 Section 335.066.1.PhoneThis field is for validation purposes and should be left unchanged.
